Bridging Care Transition After Hospitalization for Atrial Fibrillation and Coronary Interventions.

ABSTRACT: Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community-hospital-integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.

Cardioversion of pre-excited atrial fibrillation leading to ventricular fibrillation- case report and review of literature.

Pre-excited, fast conducting atrial fibrillation (AF) is a serious life-threatening arrhythmia that requires urgent pharmacological or electrical cardioversion. When anti-arrhythmic medications fail to restore sinus rhythm, biphasic, direct current (DC) cardioversion is required. Appropriate synchronization of the DC shock with the QRS is crucial, however not easily achieved. Since the QRS-T complexes in pre-excited AF are severely distorted, the diagnosis of inaccurate synchronization may be overlooked. Here, we report a unique case where during electrical cardioversion of pre-excited AF with inappropriate synchronization on the T wave inadvertently resulted in ventricular fibrillation (VF), and review the literature.

Acute pericardial tamponade due to screw-in atrial lead heart perforation.

A case of peri-procedural perforation of right atrium following the implantation of atrial screw-in lead in a 74-year-old man is reported. The perforation caused acute pericardial tamponade and worsening of the patient's clinical and haemodynamic conditions. Urgent surgical intervention with lead extraction was performed.

Causes of mortality in a department of cardiology over a 15-year period.

AIMS: Over the last four decades, in-hospital mortality from acute coronary syndromes (ACS) has declined. We characterized the patients who died in our cardiovascular intensive care unit (CICU) over a 15-year period. Based on these data, we described the changing patient population in the CICU. METHODS: This retrospective study compared characteristics of patients who died in our CICU in 2005-6, 2013-4 and 2019. During these 5 years, 13,931 patients were hospitalized; 251 (1.8%) died. The mean age of the patients who died was 76 years, 144 (57%) were men. ACS was the leading cause of admission (93 patients, 37%), and 145 (58%) patients had a history of heart failure prior to hospitalization. The leading cause of death was cardiogenic shock in 104 (41%) patients, septic shock in 48 (19%) patients, and combined cardiogenic and septic shock in 31 (12%). Patients hospitalized in the later years of the study were significantly older (67.7, 69.0 and 70.5 years, 2005-6, 2013-4 and 2019, respectively, p < 0.02) but their medical characteristics did not differ significantly between the years examined. CONCLUSIONS: The profile of the patients who died did not change significantly over the 15-year study period. Age of admitted patients was higher in later years of the study. The leading cause of admission was ACS and the leading causes of death were cardiogenic and septic shock. Based on our observations, additional skills should be added to the curriculum of cardiology, including the management of patients with multiorgan failure.

Use of a custom-designed adapter to manage ICD lead fracture.

We report the case of a 72-year-old patient with ischemic cardiomyopathy who was found to have a lead fracture in the RV coil DF-1 connector of an integrated bipolar implantable cardioverter-defibrillator (ICD) lead system at the time of upgrade to a biventricular ICD. Due to the redundant connection of the RV coil to the DF-1 connector and the ring on the IS-1 connector, a custom-designed adapter was used to exclude the site of fracture. This novel solution spared the patient the potential risks of lead extraction or abandoning the fractured ICD lead. In this way, pacing and defibrillating capabilities were fully restored, providing the patient 6 years of optimal device functioning.

Usefulness and predictive value of circulating NT-proBNP levels to stratify patients for referral and priority treatment in a specialized outpatient heart failure center.

BACKGROUND: Serum natriuretic peptide levels are useful diagnostic and prognostic markers in patients with acute decompensated heart failure, but have been little used to stratify urgency of treatment in the outpatient situation. OBJECTIVES: To examine the use of natriuretic peptide to guide priority of patient referral to a heart failure center. METHODS: We analyzed data from 70 consecutive patients with chronic heart failure (NYHA class 2-4) referred for first evaluation in a specialized outpatient heart failure center. Serum NT-proBNP was measured at the initial patient visit. We examined correlates and predictive value of mid- and upper tertile NT-proBNP for mortality in comparison with other known prognostic indicators using univariate and multivariate logistic regression analysis. RESULTS: Mortality at 6 months was 26.0% in patients with upper tertile (> 1958 pg/ml) NT-proBNP, 8.7% in the middle tertile group and 0% in the lowest tertile (P=0.017). Patients with upper tertile serum NT-proBNP levels (group 3) had lower left ventricular ejection fraction, were more often in atrial fibrillation (P=0.04) and more often had renal failure (P=0.03). Age-adjusted logistic regression analysis identified upper tertile serum NT-proBNP level as the strongest independent predictor of 6 month mortality with a sixfold risk of early death (adjusted odds ratio 6.08, 95% confidence interval 1.58-47.13, P=0.04). NT-proBNP was a more powerful predictor of prognosis than ejection fraction and other traditional outcome markers. CONCLUSIONS: In heart failure patients referred to an outpatient specialized heart failure center, an upper tertile NT-proBNP level identified patients at high risk for mortality. A single high > 550 pg/ml NT-proBNP measurement appears to be useful for selecting patients for care in a heart failure center, and a level > 2000 pg/ml for assigning patients to high priority management.

Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise treadmill test result.

The usefulness of 64-slice multidetector coronary computed tomography (MDCT) in a diagnostic triage of 100 consecutive patients (age 55.8+/-11.6 years; 57% men) with chest pain suspected to be ischemic in origin and a negative or nondiagnostic exercise treadmill test (ETT) result was examined. None of the patients had previously known coronary artery disease (CAD). MDCT showed obstructive (>or=50%) CAD in 29 patients; 13 of 59 patients (22%) with a negative and 16 of 41 patients (39%) with a nondiagnostic ETT result. High-risk (left main and/or 3-vessel) CAD was present in 3.3% of patients with a negative and 4.9% with a nondiagnostic ETT result. The 29 patients with obstructive CAD on MDCT had a higher mean Agatston calcium score (221+/-402 vs 40+/-77 U, p<0.001). Invasive coronary angiography confirmed MDCT findings in 26 of 29 patients (positive predictive value 90%) and 45 of 54 stenotic segments (83%) in a per-segment analysis. For the 71 patients without obstructive CAD on MDCT, clinically driven invasive angiography detected CAD in 1 of 15 patients (1 false-negative MDCT result) and 2 of another 5 patients who were referred for invasive angiography later during a 12-month follow-up period. In the remaining 51 patients, MDCT findings effectively allowed exclusion of obstructive CAD, and there were no major adverse clinical events during follow-up. In conclusion, in patients with chest pain possibly ischemic in origin, no previously known CAD, and a negative or nondiagnostic ETT result, contrast-enhanced 64-slice MDCT scanning was a useful tool to provide direct noninvasive coronary angiography and rapidly advance diagnostic triage.

Uses and limitations of 40 slice multi-detector row spiral computed tomography for diagnosing coronary lesions in unselected patients referred for routine invasive coronary angiography.

BACKGROUND AND AIMS: The value of multi-detector row computed tomography (MDCT) in routine cardiology practice is uncertain. We examined the applicability of MDCT imaging for the diagnosis of obstructive coronary artery disease in a routine clinical setting. METHODS: MDCT scanning (40 slice) was performed in 111 unselected patients referred for invasive coronary angiography (ICA) and findings were compared to an independent quantitative assessment of the ICA on a segmental, vessel and patient basis. RESULTS: Sensitivity and positive predictive value for segmental disease (72.2 and 70.9% respectively, overall) were higher in patients aged > or = 60 years and history of disease > or = 1 year, whereas specificity and negative predictive value were high in all groups. In the patient-based analysis, sensitivity and positive predictive value (84.7 and 87.8%, respectively) were higher, the latter in keeping with the high-patient prevalence of disease, but specificity and negative predictive value (61.5 and 55.2%) were low. CONCLUSIONS: Usefulness of MDCT was significantly influenced by age, duration of coronary artery disease and female gender, and on a patient-based analysis its diagnostic accuracy was not sufficient to replace ICA in a routine clinical setting.

A novel system for continuous, real-time monitoring of heart motion signals.

BACKGROUND: Understanding cardiac mechanics is important for developing cardiac therapies. Current modalities for assessing cardiac mechanics sample patient's heart at specific heart rate, contractility, preload, and afterload. The objective of this study was to test the feasibility of a novel system composed of intra-cardiac leads equipped with an inertial module chip (3D accelerometers and 3D gyroscopes) in monitoring continuous heart motion. METHODS: In this descriptive study, four healthy pigs were anesthetized and instrumented with motion-sensitive intra-cardiac leads; the temporal correlation between signals from motion sensors and tissue Doppler from the chest wall were studied; changes in real-time heart accelerations (ACC) and angular velocity (ANGV) were reported as percentages of change from baseline. RESULTS: Heart motion signals were sensed continuously from the right ventricular apex (RVa) and coronary sinus (CS). Volume expansion did not produce significant changes in the ACC and ANGV signals. Increasing heart rate increased the peak systolic ACC signal recorded from RVa and CS by 94 and 76%, respectively, and increased both peak systolic (61% RVa and 27% CS) and diastolic ANGV (200% CS vs. 31% RVa). Epinephrine administration increased peak systolic ACC signals at both sites (246% RVa; 331% CS). Peak systolic and diastolic ANGV increased in response to epinephrine (systolic: 198% RVa and 175% CS; diastolic: 723% CS and 89% RVa) (p = 0.125 for all changes expressed in percent). Temporal correlation between the ANGV signal and tissue Doppler signal was detected throughout all interventions. CONCLUSIONS: A novel system for continuously monitoring heart motion signals from within the heart was presented. Heart motion signals in response to physiologic manipulations were characterized.

Anemia and the Risk of Life-threatening Ventricular Tachyarrhythmias from the Israeli Implantable Cardioverter Defibrillator Registry.

Anemia was shown to be associated with increased risk for adverse events in patients with heart failure (HF). However, there are limited data on the association between anemia and the risk for ventricular arrhythmias (VAs) in patients with an implantable cardioverter defibrillator (ICD). The present study population comprised 2,352 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The risk for a first appropriate ICD shock for VA was assessed by the presence of anemia, categorized at the lower tertile of hemoglobin distribution (≤12 g/dL [n = 753]). Patients who had anemia displayed higher risk clinical characteristics including older age, more advanced HF symptoms, and atrial fibrillation (p <0.01 for all). Kaplan-Meier survival analysis showed that at 2.5 years of follow-up the rate of appropriate shocks was significantly higher in patients with low (11%) versus high (6%) hemoglobin (log-rank p <0.005). Multivariate analysis showed that anemia was independently associated with a significant 56% increased risk for first appropriate ICD shock (p <0.026). When hemoglobin was assessed as a continuous measure, each 1 g/dL reduction in hemoglobin was independently associated with a significant 8% increased risk for first appropriate shock (p <0.03). Anemia was also associated with increased risk for all-cause mortality (hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.4 to 2.27], p <0.001), HF hospitalizations or death (HR 1.78, 95% CI 1.48 to 1.13, p <0.001), but not with inappropriate ICD shocks (HR 1.24, 95% CI 0.70 to 2.21, p = 0.47). In conclusion, our findings suggest that the presence of anemia in patients with ICD is associated with increased risk for VA during long-term follow-up.

Catheter ablation of atrial fibrillation is associated with reduced risk of stroke and mortality: A propensity score-matched analysis.

BACKGROUND: Catheter ablation reduces recurrence of atrial fibrillation and improves quality of life. Only few studies have assessed the effect of catheter ablation on long-term outcomes. OBJECTIVE: The purpose of this study was to assess the association between catheter ablation and risk of stroke and mortality in patients with atrial fibrillation. METHODS: Using the computerized database of the largest health maintenance organization in Israel, we identified all adults hospitalized with a primary diagnosis of atrial fibrillation between January 1, 2005, and December 31, 2015. Of them, a total of 969 individuals who underwent catheter ablation during the same admission were matched, on the basis of the propensity of having ablation, with 3772 individuals who did not undergo catheter ablation during the same period. The cohort was followed for the occurrence of stroke or transient ischemic attack (TIA) and mortality until June 30, 2016. RESULTS: Overall, 3953 (83.4%) of patient in both groups had a CHA2DS2VASc score of 2 or greater. The incidence rate of stroke/TIA was 2.10 and 3.26 per 100 person-years in the ablation group and the nonablation group, respectively. The crude hazard ratio [HR] for stroke/TIA was 0.61 (95% confidence interval [CI] 0.48-0.79) in the ablation group compared with the nonablation group. The results were similar after controlling for CHA2DS2-VASc score (HR 0.58; 95% CI 0.43-0.72). The adjusted HRs for stroke alone, TIA alone, and mortality were 0.62 (95% CI 0.47-0.82), 0.47 (95% CI 0.20-0.78), and 0.57 (95% CI 0.47-0.66), respectively. CONCLUSION: Catheter ablation of atrial fibrillation is associated with a decreased risk of stroke/TIA and mortality in predominantly patients with a high CHA2DS2-VASc score.

Contemporary evaluation of the causes of cardiac tamponade: Acute and long-term outcomes.

BACKGROUND: Cardiac tamponade is a life-threatening state that complicates various medical conditions. The contemporary interventional era may have led to changes in clinical characteristics, causes and outcomes of cardiac tamponade. METHODS: We investigated all patients diagnosed with cardiac tamponade, based on clinical and echocardiographic findings, at a single medical center between the years 2000 and 2013. Data on medical history, index hospitalizations, pericardial fluid etiologies, and acute and long-term outcomes were collected. RESULTS: Cardiac tamponade was observed in 83 patients (52% females). Major etiologies included complications of percutaneous cardiac interventions (36%) and malignancies (primarily lung cancer; 23%), infectious/inflammatory causes (15%) and mechanical complications of myocardial infarction (12%). Sixteen (19%) patients died during the index hospitalization. Acute presentation of symptoms and lower quantity of effusion were associated with in-hospital mortality (p = 0.045 and p = 0.007). Tamponade secondary to malignancy was associated with the most substantial increment in post-discharge mortality (from 16% in-hospital to 68% 1-year mortality). During the mean follow-up of 45 months, 39 (45%) patients died. Malignancies, mechanical complications of myocardial infarction and bleeding/coagulation abnormalities were etiologies associated with poor survival (80% mortality during follow-up). Tamponade secondary to complications of percutaneous cardiac interventions or infectious/inflammatory causes were associated with significantly lower mortality (28% and 17%; log rank p < 0.001). CONCLUSIONS: In a contemporary cohort, complications of percutaneous cardiac intervention replaced malignant diseases as the leading cause of cardiac tamponade. Nevertheless, these iatrogenic complications were associated with a relatively favorable outcome compared to tamponade induced by complications of myocardial infarction, coagulation abnormalities and malignant diseases.

Programmed electrical stimulation for risk stratification of patients with ischemic cardiomyopathy.

BACKGROUND: Patients with ischemic cardiomyopathy (ICM) are at an increased risk for sudden death. Although earlier trials used programmed electrical stimulation (PES) for risk stratification, more recent data demonstrate the benefit of implantable cardiac defibrillators (ICDs) in selected patients with reduced left ventricular ejection fraction (LVEF) without performing PES. However, little is known about the outcome of non-inducible patients. The purpose of this study was to evaluate the efficacy of PES for mortality risk stratification in patients with ICM. METHODS: All consecutive patients who met the inclusion criteria (history of coronary artery disease, LVEF≤35%, and absence of documented spontaneous sustained ventricular tachycardia or aborted sudden cardiac death) were included in the study. The stimulation protocol involved up to three extrastimuli from two different sites in the right ventricle, with 180 ms as the shortest coupling interval. The primary endpoint was overall survival. RESULTS: A total of 198 patients were included in the study; of these, 60 exhibited negative (-)PES, and 138 had positive (+)PES and also underwent ICD implantation. The mean follow-up duration was 4.5 years. There was no difference in age or LVEF between the patient groups. We found a trend towards an increased 5-year survival rate in the (+)PES group in whom ICD implantation had been performed (p=0.058). Survival was significantly better in patients under 68 year olds in the (+)PES group in whom ICD implantation was performed (hazard ratio=0.3, p=0.01). The survival rate of patients ≥68 years old was similar in both groups (p=0.95). CONCLUSIONS: Non-inducibility during PES does not predict the prognosis of patients with ischemic cardiomyopathy.

Brachial artery endothelial function in residents and fellows working night shifts.

Brachial artery endothelial function, which is measured as responsiveness to reactive hyperemia (flow-mediated dilation [FMD]) was abnormal in residents and house staff after a 24-hour shift, including night duty. The greatest decrease in FMD was observed in physicians with a longer history of night-shift duty and in those reporting fewer sleeping hours during the shift. The finding that FMD is decreased after night duty raises the issue of the effects of shift duty on cardiovascular function in healthcare personnel, particularly in those undertaking night duty for a prolonged period of time.